Category: Anxiety

FAQ Regarding Psychological Practice in Geriatric Facilities

Over the last ten years, I have received multiple questions regarding psychological services in nursing homes and assisted living facilities.  Many of the questions are difficult to answer, due to the actual naming of a practice or individual.  What follows is a general fAQ for administrators and social workers to identify suspicious professional practice::

1)  They are marketed as appropriately trained psychologists when in fact most have no formal training in geriatrics, let alone dementia assessment and treatment. This is defined as “unethical” practice by the American Psychological Association.  Psychologists must have formal training in any population served or intervention offered.  My suggestion is to examine the psychologist’s vita for appropriate training.  Do not trust what marketing people have to say regarding qualifications.  See for yourself.

2)  The psychologist is working three to five days a week in your 120 bed facility. This is a recipe for ethical disaster, if not overt malpractice.  A 400 bed nursing home is not likely to offer more than 2 full days of work for most psychologists.  If the psychologist is not trained in neuropsychological assessment, one day should be plenty!  As the kids say-do the math.  Are there more than five or ten high functioning (mentally ill) residents that could profit from insight-oriented psychotherapy in your building?  Probably not.  Psychologists trained in outpatient work will fill their clinical time by treating demented residents.  It is imperative that they generate the numbers that please their respective corporations.  Medical necessity is reduced to a vague consideration.

3)  The psychologist treats dozens of residents, yet does not obtain written permission to treat any resident. A psychology corporation executive told me that an attending physician’s medical release covers psychologist’s liability as well.  This is not the historical position taken by the Florida Dept. of Health, Medicare, or the American Psychological Association.  Psychology is an independent profession that requires written permission to treat, and offers informed consent regarding the nature of the treatment.  As explained to the executive, I worked many years ago as a neuropsychologist for a company called Apogee.  A Medicare audit discovered that Apogee did not obtain written permission to treat their nursing home patients.  Medicare demanded a full refund for each patient that had not signed a release.  The company folded like a tent in a hurricane.

4)  The psychologist assigned to your facility changes every year or two. This reflects the fact that most psychologists hired by psychological corporations are young graduates.  Most have no experience in long-term care, have no formal training in dementia care, and have little desire to make a career in this area.  On the other hand, some older psychologists gravitate to geriatrics after failing in their primary area of interest.  This actually describes two owners of a local geriatric psychology corporation.  Both the young and old clinicians are similar in the sense of being inadequately trained.  They differ in that the young clinicians will move on to their chosen area of interest, and the older will cling to nursing homes as their last resort.  I do not believe either group adequately serves the interests of the residents.

5)  The psychologist/marketer offers to wave Medicare copays and treat managed care residents for free. An offer to wave Medicare copays is definitely not kosher.  Medicare rules for participating providers are clear that we must bill for our copays a total of three times!  I must admit that if I receive a letter refusing to pay, I let the matter drop at that point.  Technically, I may be in the wrong.  To tell others that I will not collect copays whatsoever is another matter.  As for free treatment of Medicaid and managed care residents, I’ll believe that when I see it.  I suspect that unpaid Medicaid patients are cured in two sessions, while all the paid residents require years of follow-up.

In summary, it is not difficult to identify unethical behavior or actual malpractice in your facility, but first you must be educated regarding the behavioral markers.  It is important to always keep in mind that psychological corporations are in your building to make money-period.  If your goal is to have all the Medicare residents billed as frequently as is allowable, I believe that you will not be disappointed with most psychology corporations.  If your goal is effective and ethical treatment of your residents, I fear you will have to look for individual experts and small dedicated group practices.  Lastly, I offer Holzmacher’s general rule of nursing home marketing as a helpful guide:

The potential for fraud and abuse increases in direct proportion to the slickness of the marketing, the frequency of the marketing efforts, and the reticence to supply the names and skills of those who actually perform the work.

Good luck!

Parenting

The October issue of the Monitor on Psychology offered seven strategies to improve parenting.  These strategies are culled from a century of research in child psychology.  This effort is especially gratifying to the author, as the bulk of important psychological research goes unnoticed and unheeded.  Please view these suggestions as ways to improve parenting, rather than a critique on the status of parenting in America.

Few activities are as bound to one’s self-worth as parenting.  Some parents will assume they employ all these techniques perfectly.  Some parents will dispel them as psychological nonsense.  Perhaps it is true that good parents often worry about their parenting skills, and poor parents believe their parenting skills are axiomatically above reproach.  This is reminiscent of how peak performers in any field tend to function.  They systematically review and analyze their performance, whereas the losers tend to blame anything but themselves.  It is hoped the parental reader will keep an open mind.

Please also keep in mind that consistency is the linchpin of any behavioral intervention.  It is probably better, most times, to employ a bad behavioral intervention consistently, than a good intervention inconsistently.  Interventions that are inconsistent leave the child confused and liable to act out in unpredictable ways.  Consistency between the caretakers must occur before the parents can employ behavioral interventions in an effective fashion.  If the parents are not in agreement about the intervention, the intervention is doomed to failure.  The child will receive a different message from each parent; again causing confusion and unpredictable acting out.  Additionally, if the child is getting what they want by pitting one parent against the other, what they are being taught is how to use deceit in order to manipulate people towards their own ends.
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That being said, the first strategy is to embrace praise, but the praise should not be indiscriminate.  Dr. Eyberg named this type of positive feedback as “labeled praise.”  The praise should be specific to the situation, realistic, and followed with a smile or gentle touch.  False praise for poor performance robs the child of the “learning that comes from failure.”  The second strategy is to ignore minor behavioral problems that do not result in physical or emotional injury.  Ignoring screaming pleas and only responding to prosocial ways of attracting attention teaches the child there are easier and more reliable methods to receive a parent’s attention.  Third, read up on child development.  New parents are often surprised by behaviors that are normal for the child’s developmental stage.  This helps to lower the parents anxiety through increasingly realistic expectations.  Fourth, use time-out in a brief and immediate fashion.  Time-outs will not work if the parents give positive reinforcement for antisocial behaviors.  The child will not stay in the corner if their aggression is rewarded at other times.  The fifth strategy is to prevent misbehavior by planning and structuring activities.  Teaching children to cope with situational demands and stay busy will help combat boredom and the disruptive behaviors that ensue.  Sixth, the parent must take care of themselves first and foremost.  There is a strong link between parental and child stress, as well as how the child will learn to cope with stress in their adult life.  Lastly, psychologists advise making time for your children.  This is not a suggestion to give up your work to sit and stare at your child.  About an hour a week, divided or whole, appears to be sufficient to satisfy the needs of most children that have been researched.  The parent should not be teaching or correcting during this time, but simply sharing an activity.

Please note that these strategies are not only effective with “normal” children, but are employed with good effect in child clinical populations.  The main difference is that these strategies are utilized in a much more rapid and rigid format.  The rules remain the same.  The primary task is to model and reward behaviors that will serve the child well in adulthood, while coping with the extraordinary responsibility and stresses of being a parent.  No one is a perfect parent, as no one is perfect at anything.  Perfection is an idealistic goal that is never attained.  It is the process of working towards this ideal that generates excellence.  So, if your worried about your performance as a parent-you’re probably a pretty good parent already.